The Pharmacist’s Role in Hospice and Palliative Care

Austin, TX—Pharmacists can play an active role in hospice and palliative care through a wide variety of approaches, including medication order assessments and counseling the hospice team, according to research presented by Bradi Frei, PharmD, MS, BCOP, BCPS, at the 11th annual Hematology/Oncology Pharmacy Association (HOPA) conference.

ASHP Statement on Pharmacists’ Role

According to the American Society of Health-System Pharmacists (ASHP), the pharmacist’s role in hospice care involves assessing the appropriateness of medication orders for patients, ensuring timely provision of effective medications for symptom control and management, counseling and educating the hospice team about supportive care through the use of medication therapy, and ensuring that patients and caregivers understand and adhere to the directions provided with medications.

“Pharmacists involved in hospice care should also work to provide efficient mechanisms for extemporaneous compounding of nonstandard dosage forms, and should find ways to get those for the patient,” explained Dr Frei, Associate Professor of Pharmacy Practice, Feik School of Pharmacy, University of the Incarnate Word, San Antonio, TX, and Clinical Instructor, University of Texas Health Science Center at San Antonio. Addressing financial concerns specifically related to medication, ensuring safe and legal disposal of all medications after a patient’s death, and establishing and maintaining proficient communication with regulatory and licensing agencies are additional roles defined by the ASHP for pharmacists in hospice care.

Furthermore, the ASHP determines that pharmacists should have a defined scope of practice in hospice and palliative care settings. “What we’re doing should be written down, particularly our activities and the limitation of those activities, as well as referral and communication guidelines,” said Dr Frei. Documentation of services is vital, and should include medical record notes. In addition, pharmacists should have a role in interdisciplinary team meetings, and should sign off on patient reviews there, she stressed.

Palliative Care Guidelines

“Palliative care specialists and interdisciplinary palliative care teams, including board-certified palliative care physicians, advanced practice nurses, and physician assistants, should be readily available to provide consultative or direct care to patients/families who request or require their expertise,” according to the National Comprehensive Cancer Networks Guidelines.1

The National Consensus Project for Quality Palliative Care’s Clinical Practice Guidelines for Quality Palliative Care includes no mention of pharmacists. “However, they say other health care practitioners could be involved,” Dr Frei added.

More Research Is Needed

“The research we have available right now concerning the pharmacist’s role really comes from Australia and Canada,” Dr Frei explained. “It doesn’t seem [like] there’s much being published about pharmacy services in hospice or palliative care in the United States.”

The reported clinical duties of pharmacists in palliative care sites in Australia and Canada involve medication review, which Dr Frei noted is the most common involvement of pharmacists in palliative care, as well as providing advice on pharmacotherapy, administration, treatment, adverse effects and incompatibilities, and educating patients. Additional duties involve participating in conferences, publications, and research, although this participation is infrequent.

Drug-Related Problems in Palliative Care

An Australian study by Hussainy and colleagues in 2011 examined the role of a pharmacist in a community palliative care multidisciplinary team.2 “This study examined what pharmacists could be doing as patients were discharged from an inpatient service into the hospice program,” Dr Frei explained. Pharmacist responsibilities in the project included creating patient education materials, conducting team educational sessions on palliative care topics, and medication review for patients enrolled in the program.

Screening patients for medication misadventure was also a cornerstone of the project. Pharmacists screened most patients (88.4%) referred to the palliative care service for risk of medication misadventure, and it was found that 14% of the patients screened needed medication reviews by the pharmacist. Eighty-eight percent of medication reviews were conducted in the patients’ homes, and 113 drug-related problems were identified; the most common problems detected were that the “patient requests drug information” (25%), and that their “condition [was] not adequately treated” (22%). “An important role of pharmacists in the project was coming back to the hospice program and updating the records to reflect what the patients were actually doing compared to what they thought they were doing,” said Dr Frei.

Results of this study suggest that the inclusion of a pharmacist in a community palliative care team can improve the medication-related knowledge and skills of its members and lead to better patient medication management. Although the study by Hussainy and colleagues furthered understanding about the role of the pharmacist in palliative and hospice care, much more research is needed in the United States to fully define the role.